Provider Demographics
NPI:1437223062
Name:MCGLOCKLIN, STEVEN DOUGLAS (MD)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:DOUGLAS
Last Name:MCGLOCKLIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3495 PIEDMONT ROAD, NE
Mailing Address - Street 2:NINE PIEDMONT CENTER
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30305-1736
Mailing Address - Country:US
Mailing Address - Phone:404-364-7000
Mailing Address - Fax:
Practice Address - Street 1:2400 MT. ZION PARKWAY
Practice Address - Street 2:KAISER PERMANENTE SOUTHWOOD MEDICAL OFFICE
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30236
Practice Address - Country:US
Practice Address - Phone:770-603-3649
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2009-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA052123207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA263919570CMedicaid
GA11BDWPQMedicare ID - Type UnspecifiedMEDICARE PROVIDER #
GA263919570CMedicaid
GAF07392Medicare UPIN
GAP00662138Medicare PIN